SURGICAL SOLUTIONS FOR THE KNEE
From Cleveland Clinic’s Knee Innovation Summit: From Birth to Death
| ANTERIOR CRUCIATE LIGAMENT (ACL) RECONSTRUCTION: BONE-PATELLAR-TENDON-BONE —
Kurt P. Spindler, MD, Kenneth Schermerhorn Professor and Vice Chair, Orthopaedics, and Director, VSM and
Ortho PCC, Vanderbilt University School of Medicine, Nashville, TN
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| Choice of graft: level 1 evidence for autograft bone-patellar-tendon-bone (BTB) and hamstring options; evidence
uncertain for allograft compared to BTB
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| Five reasons to choose BTB: based on level 5 expert opinion of speaker; 1) fixation of graft; 2) consistent match
of graft to patient; 3) science of ACL reconstruction rehabilitation based on BTB; 4) preferred graft of team physicians
in Southeastern Conference (SEC) and National Football League (NFL); 5) extremely reproducible in
speaker’s hands
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 | Fixation: BTB healing time (4-6 wk) 50% less than with hamstring graft (8-12 wk); “bone forming” screw biologic
(no hardware left behind)
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| Dimensions and quality of BTB matched to patient’s knee
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| Use of BTB precluded by: Osgood-Schlatter disease with large retained ossicle; patellar tendinosis in inferior pole
of patella; patellofemoral arthritis (grade III or IV); preoperative crepitus; “tiny knee” (eg, 100-lb woman); patellar
tendon width <27 mm
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| Speaker’s results: one infection within 1 mo of surgery in >1000 ACL repairs; no failure to harvest graft at surgery;
no fixation failure with interference screw; no transection of BTB; one extensor disruption postoperatively
in >1000 repairs
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| All but 1 athlete returned to play during 16-yr experience
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| ACL RECONSTRUCTION: QUADRICEPS TENDON —John P. Fulkerson, MD, Clinical Professor of Orthopaedic
Surgery, University of Connecticut Medical School, Farmington
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| Advantages of quadriceps tendon: easy access; low-morbidity harvest; less pain and quicker rehabilitation; preserves
hamstrings (no loss of power in flexion); no added risk for patella fracture; strong graft; possible simultaneous
harvest; better outcomes
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| Strength: thicker than patellar tendon (9 mm vs 4.8 mm; Staubli showed comparable strength); partial-thickness (7
mm) harvest preferable; no rupture in 9-yr experience; Mazzocca showed quadriceps stronger after harvest than
patellar tendon before harvest
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| Harvest: incision can be minimized for cosmesis; no risk for neurovascular damage
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| Results: 2-yr minimum follow-up; no patellofemoral morbidity; no contracture; 124 patients followed; 5 known
failures (4% failure rate)
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| Points on procedure: possible to use bone disc or polylactic acid (PLA) ball anchor for added mechanical fixation
(speaker does not use); graft should be snug in socket (ie, passage requires firm pull and probe assistance); bioabsorbable
screw placed just off joint level on tibial side; speaker’s preference—EndoButton with fiberwire or #5
Ethibond whip stitch on femoral end; Bio-Interference screw and button on tibial side
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| Pain medication: patients used “far less” after quadriceps procedure than after BTB or hamstring reconstruction
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| ACL RECONSTRUCTION: ENDOBUTTON —Richard D. Parker, MD, Education Director, Cleveland Clinic
Sports Health, Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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| Use of EndoButton: with endoscopic (usually) or 2-incision techniques; EndoButton continuous loop (strong
polyester) attaches to EndoButton and comes in various lengths to accommodate femoral tunnel in soft tissue and
BTB reconstructions
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| Advantages of EndoButton: high pull-out strength and stiffness, but not rigid (allows flexibility in tensioning);
eliminates pitfalls in interference screw fixation; accidental perforation of posterior cortex does not compromise
fixation (helpful in osteoporotic bone); makes revisions easier (no hardware in condylar notch); applicable to soft
tissue and BTB reconstruction; allows more surface area for soft tissue healing; can be used with open physis; applicable
to both single-bundle and double-bundle techniques; does not interfere with magnetic resonance imaging
(MRI) studies; in event of tunnel blow-out, ExtendoButton allows adding extension without another incision; useful
in teaching (easily reproducible procedure)
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| ACL RECONSTRUCTION: TWO-INCISION —Dr. Spindler
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| Level 1 evidence: based on speaker’s systematic review of literature; BTB and hamstring grafts equal in recreational
athlete; primary repair not better than nonoperative treatment; patellar tendon better than augmentation;
meniscal tear rate fell from 27% (nonoperative) to 3% (ACL reconstruction); no data for preventing or delaying
arthritis
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| Two-incision (rear entry) vs endoscopic ACL reconstruction: no significant difference in pain medications,
progress in rehabilitation, range of motion, strength, anterior knee pain, Tegner or Lysholm scores, or International
Knee Documentation Committee (IKDC) subjective knee score
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| Conclusion: no major clinical differences between techniques; surgeons should choose technique that has most reproducible
results in their hands
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| Advantages of 2-incision: no problems with graft-tunnel mismatch of bone blocks; femoral tunnel drilling independent
of tibial tunnel or anteromedial portal; eliminates 2 major errors with endoscopic technique (vertical grafts;
anterior tunnel placement); reproducible in speaker’s hands; easier to teach residents; since many surgeons perform
<20 procedures per year, society benefits from providing easiest and most reproducible technique
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| Technical pearls: identify over-the-top position; identify anteroposterior (AP) and horizontal positioning of femoral
tunnel; place hook around lateral femoral condyle; make 2-cm lateral incision; dissect to femur and retract
quadriceps; place rear entry guide; determine orientation and drilling of femoral tunnel; place graft passer; size
femoral bone block
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| ACL IN THE SKELETALLY IMMATURE KNEE —George A. Paletta, Jr, MD, Staff Physician, Shoulder and Elbow
Surgery, The Orthopaedic Center of St. Louis, and Medical Director, St. Louis Cardinals, St. Louis, MO
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| Epidemiology: incidence and prevalence unknown; once thought to be rare; now more widely recognized (increased
participation in competitive sports; heightened awareness; improved diagnosis)
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| ACL injuries similar to those in skeletally mature: patients 14 yr of age on average had 6% incidence of associated
chondral injuries, with meniscal pathology in 50%; in prepubescent patients with functional instability,
66% developed meniscal tears; delayed treatment increases risk for medial meniscal pathology
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| Age considerations: relation of chronologic age to skeletal development varies; Tanner staging—assesses physiologic
age; stage 1) prepubescent; stage 2) prepubescent; stage 3) pubertal (early adolescent); stage 4) pubertal (adolescent);
stage 5) skeletally mature
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| Controversies: initial management (nonoperative vs operative); operative management (technique; graft choice;
fixation; age/skeletal maturity at which reasonable to consider these procedures); complications (risks for growth
disturbance)
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| Classic treatment nonsurgical: motivated by fear of premature physeal closure; results “fairly dismal”
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| Surgical treatment options: primary repair; extra-articular reconstruction; physeal sparing techniques; partial
transphyseal techniques; complete transphyseal techniques; intra-articular reconstruction—tibial side (over-
the- front technique; transphyseal technique); femoral side (over-the-top technique; transphyseal technique)
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| Results of surgical treatment: based on level 3 and level 4 studies; “suboptimal at best”; examples—primary repair
of femoral tears (clinical laxity in 8 of 8; functional instability in 5); extra-articular reconstruction (clinical laxity
in 10 of 10; functional instability in 5); physeal sparing techniques (most used hamstring grafts; remaining laxity
in most patients; less significant instability)
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| Shortcomings of studies: retrospective; small numbers, culled from larger adult series; lack of specificity of diagnosis
(eg, concomitant pathology); lack of skeletal and physiologic maturity documentation; difficult to make definitive
conclusions
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| Basic science studies: findings suggest transphyseal reconstruction with soft tissue graft (hamstring) offers safe alternative;
animal studies indicate smaller drill holes safer, and soft tissue graft across physis might prevent formation of
bony bars; location of physis in relation to femoral attachment of ACL—speaker investigated fetal knees and pediatric
and adult knee specimens; concluded ACL femoral insertion begins ≈2.6 mm distal to physis; distance remains during
growth; over-the-top position at same level as growth plate
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| ACL reconstruction technique: speaker evaluated his results using 2 techniques in skeletally immature athletes;
group 1) partial transphyseal reconstruction; group 2) complete transphyseal reconstruction; follow-up—≥36 mo;
boys to skeletal age 15 yr, Tanner stage 4; girls to 1 yr post-menarche; conclusion—complete transphyseal reconstruction
yielded more predictable outcome (improved stability; no evidence of significant risk for premature physeal
closure); subsequent study—from February 1998 to December 2004; 59 patients (Tanner stage ≤2) with ACL
tears; ≈50% had meniscal tears; all underwent complete transphyseal reconstruction; follow-up ≥24 mo;
conclusion—predictable outcome and stability; no evidence of risk for premature physeal closure, leg-length discrepancy,
or angular deformity
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| CAPSULAR LIGAMENTS NOT REQUIRING SURGERY —Peter A. Indelicato, MD, Wayne Huizenga Professor
and Chief, Sports Medicine, University of Florida College of Medicine, Gainesville
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| Introduction: focus of presentation speaker’s approach to managing major “isolated” injuries to collateral ligaments
without surgery
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| Functional anatomy: anatomic attachments to both medial collateral ligament (MCL; quadriceps tendon) and lateral
collateral ligament (LCL; biceps tendon) actually create tension in ligaments; may explain why residual static
laxity does not lead to functional instability during activity
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| Mechanism of injury: valgus force to lower thigh or upper leg while knee extended or slightly flexed; even complete
tears of collateral ligaments can be relatively painless; complaints of weakness more common than pain
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| Physical examination: take gentle approach to enable relaxation; flex knee to ≈30° to evaluate integrity of MCL
and LCL; location of tenderness along MCL prognostic of recovery; proximal tenderness (more stiffness; slower
return to sports; less residual laxity); distal tenderness (less stiffness; faster return to sports; more residual laxity)
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| Nature of injury: collagen fibers parallel in opposite knee; asymmetry >4 mm suggests significant damage to
MCL; using ≥10 mm as definition of asymmetry may be causing underdiagnosis of complete tears
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| Imaging studies: most useful for identifying location of lesion
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| Nonoperative management of MCL tears: proximal complete tears—avoid stiffness and laxity; minimize immobilization;
begin range of motion (ROM) exercises as soon as possible, with pain as limiting guide; maintain
night splinting for 3 to 4 wk to avoid flexion contracture; distal complete tears—immobilize in extension or slight
flexion for 3 wk (choice of cast vs splint based on anticipated compliance); after 3 wk, begin ROM and progressive
resistance exercises focusing on quadriceps, hamstrings, hip and ankle joints, and calf muscles; functional brace
recommended upon return to play
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| Final point: either closed or open surgical treatment of grade 3 MCL tears not expected to completely restore medial
laxity to preinjury level; functional anatomy seems to compensate for residual laxity
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| COMBINED MCL/ACL/PCL INJURIES —Russell F. Warren, MD, Professor of Orthopaedic Surgery, Weill Cornell
Medical College, Cornell University, and Surgeon-in-Chief Emeritus, Hospital for Special Surgery, New York,
NY
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| Injury grade and management: grades 1 and 2—isolated MCL; nonoperative; combined ACL/MCL—wait; restore
range of motion; allow healing; grade 3—combined ACL/posterior cruciate ligament (PCL)/MCL; prefer to
repair early; chronic ACL/PCL/MCL—reconstruction
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| Healing: collateral ligaments may heal (medial ligaments heal better than lateral); healing response variable;
residual instability will stress graft; healing requires 6 to 8 wk; grade 2 ACL/MCL (generally wait to determine
residual instability; restore motion); grade 3 ACL/PCL/MCL (“barn door opening”; repair augmentation)
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| Collateral instability: acute medial side injuries heal with conservative care; randomized controlled trial found no
difference in results between operative and nonoperative care
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| Combined ACL/MCL injury: evidence shows healing worse when ACL combined with MCL injury; late reconstruction
yields better results than early reconstruction; chronic setting—presence of ACL injury puts stress on
MCL system
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| Study at speaker’s institution: to determine differences in outcome between early and late treatment; involves 16
patients with ACL tear and grade 2 or 3 MCL injury; underwent ACL reconstruction with BTB; follow-up at 2 to 3 yr;
group 1 (evidence of valgus instability; ACL reconstruction and MCL reconstruction ≤4 mo after injury; group 2 (without
valgus instability; ACL reconstruction ≤4 mo after injury); group 3 (“experimental group”; evidence of valgus instability;
ACL reconstruction >4 mo after injury; no MCL reconstruction); results—better in groups 1 and 2 than group 3
for subjective evaluation, activity level, and KT-1000 findings
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| Concluding comments: “notion that all medial side injuries will tighten down applies to the acute injury only, and
there are some that do not”; significant and chronic medial instability prior to ACL reconstruction should be addressed
surgically; ACL reconstruction dampens medial side instability, giving false sense that medial side stable; residual
medial instability puts excess stress on ACL graft
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Suggested Reading
Adams DJ et al: Residual strength of the quadriceps versus patellar tendon after harvesting a central free tendon graft.
Arthroscopy 22:76, 2006; Behr CT et al: The relationship of the femoral origin of the anterior cruciate ligament and
the distal femoral physeal plate in the skeletally immature knee Am J Sports Med 29:781, 2001; Fulkerson JP et al:
An alternative cruciate reconstruction graft: the central quadriceps tendon. Arthroscopy 11:252, 1995; Hillard-Sembell
D et al: Combined injuries of the anterior cruciate and medial collateral ligaments of the knee. Effect of treatment
on stability and function of the joint. J Bone Joint Surg 78:169, 1996; Jarvela T et al: Anterior cruciate ligament reconstruction
in patients with or without accompanying injuries: A re-examination of subjects 5 to 9 years after reconstruction.
Arthroscopy 17:818, 2001; Kocher MS et al: Management and complications of anterior cruciate ligament
injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop
22:452, 2002; Muneta T et al: A prospective randomized study of 4-strand semitendinosus tendon anterior cruciate
ligament reconstruction comparing single-bundle and double-bundle techniques. Arthroscopy 23:618, 2007; Oh YH et
al: Hybrid femoral fixation of soft-tissue grafts in anterior cruciate ligament reconstruction using the EndoButton CL
and bioabsorbable interference screws: a biomechanical study. Arthroscopy 22:1218, 2006;Spindler KP et al: Anterior
cruciate ligament reconstruction autograft choice: bone-tendon-bone versus hamstring: does it really matter? Am J
Sports Med 32:1986, 2004; Staubli HU et al: Mechanical tensile properties of the quadriceps tendon and patellar ligament
in young adults. Am J Sports Med 27:27, 2001.
Educational Objectives
| The goal of this program is to provide contemporary advice on managing ligamentous injuries of the knee. After
hearing and assimilating this program, the orthopaedic surgeon will be better able to:
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| 1. Perform anterior cruciate ligament (ACL) reconstruction using the bone-patellar-tendon-bone technique.
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| 2. Choose among the quadriceps tendon, EndoButton, and 2-incision options for ACL reconstruction.
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| 3. Manage ACL injuries in the skeletally immature knee.
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| 4. Identify and treat capsular ligament injuries not requiring surgery.
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| 5. Provide appropriate therapy for combined injuries of the ACL, posterior cruciate ligament, and medial cruciate
ligaments.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 month that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the following has been disclosed: Dr. Fulkerson—dj Orthopaedics
(royalties)
Acknowledgements
All speakers were recorded at A Knee Innovation Summit: From Birth to Death, sponsored by the Cleveland Clinic,
April 11-14, 2007, in Cleveland, OH. The Audio-Digest Foundation thanks the speakers and the Cleveland Clinic for
their cooperation in the production of this program.
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